Healthcare Provider Details

I. General information

NPI: 1407446941
Provider Name (Legal Business Name): BEVERLY DENTISTRY AND BRACES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DODGE ST STE A-190
BEVERLY MA
01915-1705
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE STE 300
MARLBOROUGH MA
01752-1900
US

V. Phone/Fax

Practice location:
  • Phone: 508-872-3072
  • Fax: 508-872-0781
Mailing address:
  • Phone: 508-872-3072
  • Fax: 508-872-0781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. JOANNE TAVANO
Title or Position: CFO
Credential:
Phone: 978-580-1524